1366531162 NPI number — TRICIA L ETHERIDGE M.D.

Table of content: TRICIA L ETHERIDGE M.D. (NPI 1366531162)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366531162 NPI number — TRICIA L ETHERIDGE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ETHERIDGE
Provider First Name:
TRICIA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366531162
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
109 S GREEN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIDGELAND
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29936-9165
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-726-6773
Provider Business Mailing Address Fax Number:
843-726-6778

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
109 S GREEN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIDGELAND
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29936-9165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-726-6773
Provider Business Practice Location Address Fax Number:
843-726-6778
Provider Enumeration Date:
10/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  19547 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 320114664 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 42D1028556 . This is a "CLIA" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: DC4084 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 320114664 . This is a "TAX ID" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 19547 . This is a "LICENSE #" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: L25587 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com